Imaging services at the University of Rochester Medical Center include general, diagnostic, and specialty radiology for patients with numerous medical, pediatric, and surgical conditions.
Pertinent clinical history and accurate coding are essential. Ordering physicians need to assure that documentation supporting the need for imaging studies is complete and adequately details patient signs and symptoms. This information dictates how examinations are performed, protocoled, and interpreted, thereby directly impacting patient care.
In an effort to provide excellence in patient care and to comply with established regional and national guidelines, the following criteria must be met when ordering imaging exams:
- ICD code(s) provided on the requisition.
- Narrative description of pertinent patient history, signs, and symptoms. "Rule out" or similar phrases are not acceptable.
- The records of the referring physician must reflect the same signs and symptoms supplied on the exam requisition.